Category: Book Reviews

Lisa Tessman’s When Doing the Right Thing is Impossible offers an engaging and accessible exploration of the complex philosophical issues surrounding moral dilemmas and moral failure. Are there genuine moral conflicts? Is it true that in some situations a moral agent cannot help but fail? Tessman offers her own answer – yes, in some situations, moral failure is unavoidable – while guiding readers through the debates surrounding these questions, clarifying the various positions sympathetically and carefully.

Part of what makes the book so immediately gripping is the case study it begins with in Chapter One: Tessman focuses on the case Memorial Medical Center in New Orleans during Hurricane Katrina. During the storm, the hospital was full of patients as well as a number of community members, off-duty staff and their families who were seeking shelter. In the aftermath, the hospital was seriously compromised—the air conditioning stopped working, the water became unsafe to drink or wash with, toilets stopped working, and medications ran low. Some critically ill patients were evacuated by helicopter, but many more were not. As time went on, exhausted staff and volunteers made mistakes, and doctors and administrators made pressured judgment calls, including the decision to go into lockdown and post armed guards to keep out desperate people (seen as potential looters) trying to get in. After being trapped in the hospital for four days, the backup generators failed and the situation worsened further. Staff, nurses, and doctors acted heroically: they pumped oxygen by hand for patients who had required ventilators, and designed IV drips that would not require electricity. But, in desperation, they began to make decisions about who would most deserve evacuation, now with a plan to leave those who were either most sick and therefore least likely to survive evacuation, or too large and unwieldy to move, for last. When it became clear, given complex and horrifying circumstances, that not everyone would be evacuated, according to some accounts, some doctors and nurses gave injections of morphine and other drugs to hasten the deaths of those who would not be.

The question Tessman raises from this case is the one at the heart of the book: are there situations in which what agents are morally required to do is something that is impossible to do? As in the case of the doctors and nurses, we might think they were both morally required to not leave patients in the hospital to suffer and die, and at the same time that deciding to give patients who might survive a drug to hasten their deaths was morally reprehensible. Or, put differently, we might think they were morally required to save their patients but also that saving their patients was impossible—they were morally required to do something they could not do. Giving a philosophical account of how this can be the case is complicated, given some fundamental commitments that shape much of philosophical ethics. For one thing, as Tessman notes, if we agree with her that there can be impossible moral requirements, then we must be willing to contradict the Kantian principle “ought implies can” (16).

Chapter two takes up the question of whether moral dilemmas can in fact exist. Tessman distinguishes moral conflicts (i.e., situations in which there is a moral requirement to do both A and B and one cannot do both A and B) from moral dilemmas (i.e., situations in which there is a moral requirement to do both A and B, one cannot do both, and neither ceases to be a moral requirement as a result of the conflict). In the case of dilemmas, even if an agent judges that moral requirement A overrides moral requirement B, B does not stop being a requirement. Failing to do B, even in order to successfully do A which the agent judged to be more important, would still be a moral failure. As Tessman notes, many philosophers believe that moral dilemmas do not exist. She canvasses two “anti-dilemma” philosophical positions: those who argue that there are no moral conflicts at all (the ‘no-conflict approach’), and those who argue that there are no moral conflicts that count as dilemmas (the ‘conflict resolution approach’). Tessman ultimately rejects both approaches, the first by rejecting the principle that ‘ought always implies can’, and the second by arguing that there are some cases of conflicting moral requirements where both requirements are non-negotiable and neither can be overridden or cancelled. As she concludes, “as long as some moral requirements are non-negotiable, then if there are conflicts among these kinds of requirements, there will also be dilemmas” (42).

The third chapter of the book considers how to distinguish between negotiable and non-negotiable moral requirements. Those that are negotiable may conflict without producing circumstances of moral failure: we can simply prioritize the more important, non-negotiable requirements over those that are less important. But where non-negotiable requirements conflict, moral agents can find ourselves failing no matter which requirement we fulfill. Tessman distinguishes different kinds of moral requirements—there is a plurality of kinds of moral values (47), and because not all moral values are of the same kind, they cannot always substitute for one another. In some cases, the value of an action can be replaced by some other value. In other cases, an action’s value is irreplaceable. In particular, there are cases of some values which, if sacrificed, could never be replaced. Tessman gives the example of the murder of someone you love. Nothing can substitute for what you have lost: it is a loss of an irreplaceable value. Irreplaceability seems to be one component of what makes some moral requirements non-negotiable, but not the only component, since some irreplaceable losses are not substantial enough to count as non-negotiable moral requirements (e.g., a child losing a beloved balloon may be an irreplaceable loss but not one her parent is obligated to prevent at all costs). As Tessman argues, drawing on Gowans (Gowans 1994) and Nussbaum (Nussbaum 2011), the more serious, non-negotiable requirements, are ones which nothing can substitute or compensate for fulfilling, and ones which provide what is of deepest value in human lives.

In the fourth chapter, Tessman turns to the work of empirical moral psychologists to consider further how moral agents could judge ourselves to be facing non-negotiable moral requirements. Contrary to the common philosophical assumption that processes of moral judgment are chiefly processes of reasoning, Tessman surveys Jonathan Haidt and Joshua Greene’s work on dual process models of moral judgment, which consider how moral judgments of non-negotiable requirements might more standardly occur through automatic, unconscious, intuitive processes. The difference between reaching moral judgments through intuitive processes and reaching them through reasoning processes suggests a way of distinguishing negotiable and non-negotiable requirements: the alarm bell emotions that accompany the intuitive process of moral judgment may be part of what distinguishes judgments that some moral requirements are non-negotiable. As Tessman writes, “If you see a vulnerable person in danger, for instance, and this immediately provokes an ‘I must protect!’ alarm bell, then you’ll experience the moral requirement indicated by this ‘I must’ as non-negotiable” (76).

In chapter five, Tessman considers the evolutionary development of moral practice more broadly. Focusing on multilevel selection theory, Tessman explains how traits tied to abilities to cooperate and be altruistic (specifically, the traits of individuals in groups who successfully practiced alloparenting) have been seen as more likely to be passed on (82). Having gone into detail on the view and common misconceptions to be avoided, Tessman highlights this as a plausible evolutionary explanation of why morality in general would have involved, and proceeds to concentrate on evolutionary explanations for the specific experiences of intuitively judging that we are required to do something. In brief, she notes that we have good evolutionary explanations for why humans rely on system 1 (the quick, intuition system of the dual system models) associating certain perceptions (e.g., of an object that looks like feces) with certain feelings (e.g., yuck) and behavior (e.g., do not eat) (94-95). Moral responses (e.g., “vulnerable person in danger/empathic fear for the person/protect the person!”) could have evolved similarly (98). The presence of such moral responses does not ensure that they are ones we can enact, of course, since we cannot always protect the person. In such cases, we may face impossible moral requirements.

Tessman turns in chapter six to a consideration of second-order judgments about our first-order judgments of what action is morally required. In particular, she argues that a specific class of first-order judgments arrived at by intuition should not be subjected to verification by a reasoning process, because to do so would actually undermine the value expressed in the first-order judgment. For instance, a parent’s first-order automatic judgment that they must stop their toddler from running into a busy street should not be subjected to second-order evaluation (108). To do anything other than stop the child is unthinkable. As Tessman writes,

“If intuitively judging some actions to be unthinkable is part of what constitutes loving someone, and if judgments of unthinkability preclude double-checking our intuition through reasoning, then in order to love in this way we’ll have to trust some of our intuitive judgments about what actions are required or prohibited, and to do so without relying on any reasoning about them” (109).

On Tessman’s view, this amounts to both a first order intuitive judgment (i.e., one must stop the child), and a second order intuitive judgment [i.e., “Don’t think the unthinkable by reasoning about what to do in this case!” (110)], at the same time. In some cases, agents might face either doing the unthinkable (e.g., not protecting one’s child) or doing the impossible (e.g., lifting a 5000-pound car off of them). In these sorts of tragic cases, one cannot help but fail.

In chapter seven, Tessman continues the consideration of unthinkable actions, but now in contexts of relationships beyond those of intimates. In some cases of moral action, it can be wrong to arrive at a moral judgment via controlled reasoning rather than an affect-laden, automatic, intuitive process. For instance, we should not need to think very hard about whether to save a child’s life. In the words of Bernard Williams, it can be possible to think ‘one thought too many’. As Tessman writes, “We should treat other people as beings whom it is unthinkable to do certain things to, and the mark of our finding these things to be unthinkable is that we don’t have to reason, or find justification, in order to grasp that we mustn’t do them” (133). While recognizing and honoring sacred values can be at the core of much of the most important moral actions, doing so can also be dangerous—we must also remain attentive to the values that conflict with them.

In chapter eight, Tessman concludes that, contra constructivists and theorists who think we should reach consistency among moral values by processes of reflective equilibrium, morality is not necessarily made up of a consistent set of judgments reached by reasoning. In fact, the set of our moral values is often arrived at through an automatic, intuitive process, and may persistently contain conflicting values. We should not respond to the existence of conflicting values with an attempt to tidy them up and produce a unified, consistent set.

One of the most important dimensions of Tessman’s work in this text as I see it is its reflection on why the possibility of unavoidable moral failure can feel so troubling to moral agents, despite the fact that such situations are not rare in our moral lives. As Tessman notes,

“It’s very distressing to think that, due to something completely outside of your own control, you might be caught in a situation in which you’re inevitably going to have to commit a moral wrongdoing. Perhaps we like to think that we can control how morally good or bad we are. If there are dilemmas, then even if we always try to do the right thing, we might end up with no right thing that we can do…We can expect our moral lives to be less clean than we might have previously imagined because we might fail in ways that we never would have, if only it were always in our control to avoid moral failure…The point of recognizing the phenomenon of unavoidable moral failure isn’t to identify more things that people can blamed for. Instead, the main point is to acknowledge how difficult moral life can be” (29-30, 159-160).

Her reflection on the allure of control in moral lives will be helpful both at the level of philosophical developments in moral psychology, as well as at the level of on-the-ground first-person moral experience.

This is an excellent book not only for philosophers working in ethics and moral psychology, but also for a much broader audience. It would be ideal for use in ethics classes, and is accessible enough for readers beyond academic contexts who are interested in understanding the complexities surrounding these all-too familiar experiences. Throughout, Tessman helpfully frames questions to the reader (e.g., “are you willing to agree that…?”), making the text especially engaging, and facilitating its use in classrooms and discussion groups. The book manages to maintain what is deeply relatable about situations in which moral agents cannot succeed, while introducing readers to the philosophical controversy surrounding such situations.

This fascinating anthology focuses on the question of how we make families, and how bionormative assumptions shape ordistort our collective thinking about parenting, children’s welfare, and state obligations to parents and children. The editors are primarily interested in the question of whether parents’ moral responsibilities toward children differ for children produced through assistive reproductive technologies (ART)compared to children brought into the family via adoption. As the editors point out, in the realm of ART, most of the philosophical literature has been focused on parental autonomy and rights to assistance in reproducing, while the adoption literature is almost entirely focused on the protection of children. The anthology does an excellent job of exploring this disconnect, and probing assumptions about moral responsibilities within family-making. Taken as a whole, the chapters explore “whether people should rely on others’ reproductive labour in having children, whether they should ensure that they will have a genetic tie to their children or that their children will have some connection to genetic relatives, whether they should bring a new child into the world at all, whether they should agree to what the government would require of them for an adoption, where they should live if the family they make is multi-racial, at what age they should forgo having children, and the list goes on” (6).

The first section of the book sets the stage with two excellent chapters on the goods of parenting (Harry Brighouse and Adam Swift) and the goods of childhood (Samantha Brennan). The goods of parenting are distinguished from other related goods—intimacy with another adult or friend, friendship with a child, being an uncle, having a pet, etc.—and understood to be extremely valuable and non-substitutable (13). Brighouse and Swift identify at least four things that distinguish parent/child relations from these other intimacies: 1) they cannot have equal power, given that children do not enter the relationship voluntarily, are dependent, and cannot exit at will; 2) parents have the power to (indeed are often expected to) coerce children; 3) parents set up the environment that creates a child’s values and possibility for autonomy; and 4) parents receiveunconditional intimacy from the child, and presumed trust (15-16). These distinct features of the parenting role lead to unique goods of parenting, and highlight some of the reasons we often consider access to family-making to be a fundamental right. The authors note that parenting is “likely to be one of the most important things one does with one’s life” (19). Like romantic relationships, parenting may not be necessary for a good life, but it is often a very significant component. Importantly, though, the goods of parenting are not necessarily tied to biological parenthood, but are instead gained through the intimate, unique relational role and resultant experiences.

Brennan’s chapter on the goods of childhood takes on the question of how much of children’s welfare (and parental obligations to promote it) is attached to the present child vs. the future adult she will become. A parent’s job isn’t simply to get the child to survive until adulthood, or even to have an “open future,” but also to help her enjoy the unique goods of childhood, including for instance, free play, a sense of time as endless, a sense that all doors are open, and absolute trust in others (43). On Brennan’s view, children aren’t small or deficient adults, but developing relational, autonomous creatures who need help to pursue their own temporal goods.

Part two of the book critiques the ways in which bionormativity (the idea that the “gold standard” of the family is having parents who are genetically related to the child) influences our thinking and policy-making on family creation. The chapter by Charlotte Witt takes on David Velleman’s arguments (Velleman 2005,Velleman 2008) regarding the importance of having “family resemblance” for developing a healthy and adequate identity or sense of self. Velleman considers it to be “universal common sense” to think it better to have one’s own biological parents (quoted on 54), and argues explicitly against making children with anonymous gamete donors. In his view, “Not knowing any biological relatives must be like wandering in a world without reflective surfaces, permanently self-blind” (quoted on 52). Witt does an excellent job of showing just how limited this view is, given the multiple ways we can see ourselves reflected in the behaviors, beliefs, and practices of our rearing parents, even if they are biologically unrelated. The fact that many adoptees seek information about their biological parents may show curiosity or the desire for medical information rather than “genealogical bewilderment” that impinges on healthy identity formation.

A more empirical chapter (Lucy Blake, Martin Richards and Susan Golombok) reviews the evidence regarding the health and well-being of children and families formed through natural sexual reproduction, ART, and adoption, and concludes that there is no good evidence in favor of the bionormative conception of the family. Children produced through ART with donor gametes had no significant health or psychological differences from children produced via natural sexual reproduction (78), and ART parents were just as likely (or more so) to have positive parenting ratings. Their comparisons for adopted children show somewhat greater psychological and behavioral issues, but they argue that these are more likely to occur in children adopted later in life, and are probably due to the lingering effects of early stresses (e.g., neglect, abuse, malnutrition) prior to the adoption rather than to having biologically unrelated rearing parents.

Part three looks at becoming a parent, with chapters from Christine Overall on the value of procreation, and Tina Rulli on the value of adoption. Overall argues that most of the reasons given in favor of procreation (e.g., bringing intrinsic value into the world, creating happy people, enjoying the experience of pregnancy, childbirth, and breastfeeding, fulfilling duties to family, obeying religious requirements, maintaining choice and control in reproduction) fail to justify procreation over adoption, because they misunderstand the parent/child relationship, have too narrow a vision of what parenting is, or lead to troubling implications.

Rulli offers a look at the unique goods of adoption, highlighting the ways in which adoption “provides a morally noble opportunity to extend to a stranger benefits usually withheld for one’s genetic kin” (110). She argues that adoption is sometimes superior to procreation; it’s a “pure and exemplary model of what is most valuable about parenthood” (110). Consider Rosalind Hursthouse’s claim (Hursthouse 1987) that it is tempting to consider “bearing a child as analogous to sacrificing a fair amount of time and effort to saving someone’s life” (quoted on 114). Rulli uses this insight to note that not only does adoption satisfy the moral features that give procreation value (e.g., having the courage, fortitude and endurance to create something of intrinsic value, investing time and energy toward “saving” lives, developing intimate relational connections that are central to morality), it does so in clearer ways, given that adoption involves the risk of taking on a stranger in need, rather than creating a new life. (“Procreation doesn’t meet needs; it creates them” 113.) As such, Rulli suggests that “adoption is not second-best. Morally speaking, it is the exemplar” (115). Importantly, she is not arguing for a duty to adopt, but against the assumption that adoption is always second-best. Rulli also considers objections about the “myth of the world orphan crisis” that may create a demand for children (and a market for babies in less developed or more impoverished parts of the world). She rightly notes that concerns about unscrupulous adoption markets and practices call for better oversight, not abandoning or maligning the value of adoption.

The fourth part of the book looks at state interests related to people who want to become parents. Jurgen De Wispelaere and Daniel Weinstock consider whether the state has an interest in restricting access to ART (or at least not subsidizing it) in order to address the needs of already existing children who are awaiting adoption. They note that while some have argued for a positive right to ART (under the banner of a right to reproductive health), using ART often looks more like enhancing reproductive function as opposed to restoring it, and the reproductive health right frame over-medicalizes the process of family-making. One might make a claim instead to a positive right to parent, but that right does not require any biological connection between parent and child (137). If the state should recognize a fundamental right to parent, but remain neutral between modes of fulfilling that right (i.e., natural sexual reproduction, ART, and adoption), then it might seem that the state would have no justification for promoting any one mode of family-making. But third party interests (those of existing children in need of adoption) alter the situation, giving the state reason to promote adoption and perhaps restrict access to ART. Nonetheless, the authors resist the conclusion that access to ART should be restricted, because they recognize costs of the adoption process, the limited pool of potential adoptees (especially given restrictions on international adoptions), and the potential difficulty in providing a good home for a child with special needs. A solution might be to open up the adoption process a bit more (making it more feasible for some prospective parents), and to institute some restrictions on access to ART. Regarding the latter, they suggest that we manage demand for ART through pricing (with the state partially subsidizing it only for impoverished infertile people). They recognize the right to parent, but think that right ought to be focused on intimacy and special relations rather than biological connection.

In their chapter, Carolyn McLeod and Andrew Botterell offer lessons from their own experience as adopting parents. They note that prospective adoptive parents are in for a time-consuming, frustrating, sometimes intellectually numbing process that involves extensive interviews, home visits, required parenting classes, letters of reference, criminal background checks, and more, in a process that can last more than two years. Their question is whether the state should have the right to impose these constraints on adoptive parents (and, to be specific, on non-related adoptive parents) but not on “natural” parents (or familial or step-parent adopters). They argue that the differential treatment is not morally justified, because all the reasons offered to justify licensing only non-familial adoptive parents (harm to prospective children, feasibility of licensing, transfer of parental responsibility during adoption, and lack of claim by prospective parents to a particular child) are not non-familial-adoption–specific worries. They conclude that we either ought to support licensing for many more prospective parents, or not licensing at all (155).

Julie Crawford’s chapter takes on the issue of bionormativity in the law’s treatment of “second parent adoption” vs. parental presumption. As a lesbian co-mother who helped with the “ontological choreography” of creating a child with her partner, Crawford was nonetheless required legally to adopt her child in order to be considered a legal parent. Contrast this with the legal practice of parental presumption (176-177), which allows a man in her role to bypass the adoption requirement. An anonymous sperm donor for a couple using ART is removed from the legal parenting equation and “the social father seamlessly takes his place” (174) and is automatically the baby’s legal father. This is what Elizabeth Bartholet(Bartholet 1995) calls a “technologic adoption.” What could possibly justify this difference, given their structural similarities? Crawford notes also that second parent adoptions can run $4,000-6,000 and take time, during which the second parent does not have legal parental rights. She advocates for extending the parental presumption to parents in committed relationships (whether married or not).

Part five turns to special responsibilities of parents, with chapters on responsibilities of parents using ART (Jamie Lindemann Nelson), post-adoptive parental obligations in regard to openness and disclosure within and outside of the family (MiannaLotz), and obligations for parents who adopt transracially to morally consider the geography (neighborhood of residence) of their new family (Heath Fogg Davis). Nelson’s chapter highlights how parental responsibilities are not the sorts of things that can be “unilaterally dissolved” (186). Nelson notes that what we cause to happen can matter morally, so even if we didn’t intend a particular effect, we can be morally responsible in relation to it (188). This means that the anonymous sperm donor may have some responsibility toward the child produced through ART, if only related to the provision of information. Similarly, parents who use ART and rely on a gamete donor may have the responsibility to share such information with their child. As Nelson smartly points out, “If some adults can find biological relationships with children so important that it makes going through ARTs with all their costs, risks, and inconveniences a rational choice for them, why should we assume that biological ties in the other direction won’t also matter greatly to some children?” (189).

Lotz argues that adoptive parents have obligations to communicate openly about the adoption within their family, in order to help address three vulnerabilities of adopted children: identity development, development of a sense of familial belonging and security, and development of emotional independence (201). Post-adoptive parental obligations, then, may involve initiating discussions about adoption and the child’s heritage rather than only being responsive to questions from the child. Still, she distinguishes between obligations of openness within the family, and outside of the family, noting that concerns about adoptee welfare may make extra-familial openness optional rather than required.

Fogg Davis’s chapter takes up the intriguing question of whether parents in transracial adoptions are morally obligated to make their homes in non-predominantly–white neighborhoods. Fogg Davis argues that they are, not because a black adopted child cannot form a healthy self-concept in a white neighborhood (we have many examples to the contrary), but because such parents have a “magnified version of the general moral responsibility that we all have to make residential decisions that do not perpetuate longstanding patterns of racially segregated housing” (222).In transracial adoptions, the family itself is a site of racial integration (223), and the parents have assumed leadership roles in relation to racial integration. “Parents are morally obligated to convey the message to their black adopted children that the racial integration of the family will not be entirely unidirectional, that they are willing to physically move out of their geographical racial comfort zones. The parents show good faith in leading the family’s process of racial integration by interrupting the unthinking cycle of selecting a neighborhood that is racially familiar to them” (227).He acknowledges that this obligation is held by all parents, but suggests that it is magnified in the case of white parents who adopt black kids.

The final part of the book includes chapters on “contested practices,” including the use of “right to know” analogies between ART and adoption practices (Kimberly Leighton), contract pregnancy in India (Françoise Baylis), and age restrictions for the use of ART (Jennifer Parks). Leighton argues that the circumstances of ART and adoption are different enough that the purported harms of not knowing one’s genetic parent are not easily comparable across these practices.

Baylis offers a damning look at contract pregnancy (surrogacy) practices in India, which in her view amount to unfair exploitation of impoverished Indian women by privileged Westerners, despite some surrogates’ testimony to the contrary. When a surrogate complains about the exhaustion of pregnancy but notes that her regular job (crushing glass 15 hrs/day for $25) is truly exploitative, Baylis acknowledges the truth of her testimony, but focuses on the structural injustices that make this kind of “choice” the best available option (268). She also points to less sanguine testimonies from women who say that contract pregnancy is far from what they would otherwise choose, but they really have no other feasible option—even as their contracting couples from the West claim that the women think they are doing something good, and “in their eyes, they aren’t being exploited”(269). Paying the women more would not resolve the situation, given that in their situation, more money would simply constitute undue inducement (272). Baylis focuses less on the responsibility of individual women, and more on the governmental policies that encourage such international contract pregnancy: “The job of government is not to expand the range of exploitative work options available to its citizens, but rather to guard against exploitation and oppression” (274). She starts by examining the harms to the women who are exploited, but also considers the harms to the children who are created this way, including the potential difficulty of living with an autobiography that is incomplete or that includes complicity in exploitation, or being understood as a commodity. Finally, she does not let the contracting couples off the hook, but appeals here to the work of Iris Marion Young (Young, 2007), noting that we are individually responsible for structural injustices, given the ways that we play our parts in the process (282).

The final chapter takes on the issue of age restrictions for the use of ART. Several sensational media cases depict women in their sixties and seventies using ART in order to become parents. Critics raised concerns about the prospect of orphaning the children at a relatively young age, the parents not having the energy or ability to guide the child well (given the exhausting if joyful work of parenting), and the physical and psychological problems that might be associated with older age parenting (288). Parks argues that many of the reasons offered against the use of ART by older women) are not exclusive to them, but might be leveled against women in their usual reproductive years who use ART because of cancer or other health-related concerns. Additionally, she argues these objections could be assuaged through careful planning for help with chronic care, plans for transfer of guardianship, etc. Parks also notes that cryopreservation of one’s own eggs for possible use in IVF can aid women who want to be mothers beyond their typical reproductive years. While Parks recognizes critiques of those who frame cryopreservation as a feminist technology—Barbara Katz-Rothmann(Katz-Rothmann 2012) wonders why we don’t make other options feasible during women’s reproductive years (quoted on 289), and Patricia Smith (Smith 1993) worries it is technology that reinforces the importance of a women producing a biologically-related child for her partner (299)—she ultimately argues that it is rightfully considered a feminist technology because it provides “tools plus knowledge that enhance women’s ability to develop, expand, and express their capacities” (quoting Linda Layne et al. 2010, on 297). It offers women the option to put off reproduction while they pursue careers or other interests, and can serve as a kind of “insurance policy” for the future. Cryopreservation also decreases the number of women who would otherwise rely on donor eggs to attempt procreation, and thus may help to address concerns about exploitation and physical risk related to third party donation of eggs.

In sum, Family-Making is filled with philosophically rich explorations of the nature and limits of parental obligations to their children, whether the children enter their families through sexual reproduction, ART, or adoption. In reading these essays, I found myself longing for the goods of childhood, cherishing the joys of parenting, and marveling at the many-splendored nature of our familial structures and the weighty (and sometimes confusing) moral responsibilities that attach to them.

Sara Goering

Department of Philosophy

University of Washington

Seattle, WA, USA

REFERENCES

Bartholet, Elizabet. 1995.“Beyond Biology: The Politics of Adoption and Reproduction.”Duke Journal of Gender Law and Policy 2(1): 5-14.

The idea that prescribing physicians should be guided by the most reliable scientific evidence seems obvious, but the actual methodology of evidence-based medicine was only introduced in the early 1990s by an international group of clinicians and researchers led by Gordon Guyatt. Since then it has provided a new paradigm for the scientific foundation of medicine and has influenced other disciplines outside of medicine, for example, evidence-based psychotherapy, science and government. The novel concept of evidence-based medicine is based on hierarchies of evidence from opinions of respected authorities, mechanistic reasoning (pathophysiologic rationale), and reports of expert committees at the bottom to various levels of observational studies and finally to randomized clinical trials (RCTs) at the apex of the pyramid. Since RCTs provide the most rigorous testing of therapies, they are the gold standard. When treatments long believed to be safe and effective are subjected to RCTs, many turn out to be as useless as the quackery of snake oil or as harmful as mercury. So, attention to RCTs as the evidence informing clinical judgment and practice is perhaps analogous to results of rigorous experiments in physics which turn out to be very different from our intuitions. Everyone, it seems, is on the bandwagon, from medical societies and pharmaceutical companies to general practitioners and surgeons, in the quest for an evidence-based practice.

Since evidence-based medicine was conceived with the practical aim of improving the efficacy of medicine, it does not appear that there is much of philosophical interest in the concept until one raises the epistemological question, as Jeremy Howick does in this book: What is the evidence for evidence-based medicine philosophy of evidence (9)? In other words, what is the evidence that evidence-based medicine is any better in improving patient outcomes than medical practice before the new paradigm? So, evidence-based medicine requires evidence and this is what Howick attempts to achieve in this splendid treatment of the subject. With an eye on the philosophical, Howick is also concerned with various paradoxes that arise concerning the hierarchies of evidence-based medicine; for example, many treatments in whose effectiveness we have the most confidence have never been subjected to RCTs, including simple procedures such as the Heimlich maneuver and tracheotomy. Howick’s thesis is that the evidence-based medicine hierarchies are sustainable provided that we take into account certain modifications, for one that “strict hierarchies should be replaced by the requirement that all evidence of sufficiently high quality should be admitted as evidential support” (xiv, 187). This being the case, we need not subject treatments we know to be effective to RCTs, for this would be as redundant as the need to test parachute effectiveness against parachute placebo.

In order to qualify as good evidence for an evidence-based medicine, outcomes must be clinically effective (clinically significant, rather than merely statistically significant) according to which: (i) patient-relevant benefits outweigh any harms, (ii) the treatment is applicable to the patient being treated, and (iii) it is the best available option (24). The evidence must demonstrate that the patient will live longer or better. Good evidence also rules out plausible rival hypotheses (33). So, RCTs generally maintain their position in the hierarchies because when well-designed and well-conducted (double-masked and randomized), RCTs minimize confounding factors such as the expectation of patients to recover by knowing they are given the experimental treatment. Observational studies cannot meet this standard because they involve observations in routine practice that cannot rule out the confounding factors. Certain observational studies will claim a treatment to be effective and safe but, when subjected to rigorous RCTs, show the very opposite. The same relationship holds between conclusions drawn on the basis of mechanistic reasoning and well-conducted clinical studies. Faced with contradictory conclusions from results in the hierarchies, Howick says it is rational to bet on the results form RCTs since RCTs are less likely to suffer from bias (53).

However, Howick introduces his rule of evidence: comparative clinical studies (or observational studies more generally) provide good evidence when the effect size outweighs the combined effect of plausible confounders (56). In cases in which the effect size is dramatic, potential confounders ruled out by double masking are outweighed by the effect size. So, for example, a retrospective or naturalistic study of the effectiveness of a new antidepressant in which eighty percent of the patients responded to treatment would not be good evidence since confounding factors for subjective ratings could provide alternative explanations, but in a similar test in which antibiotics for meningitis produced dramatic results, potential confounding factors are unlikely to account for the outcome of the study. Generally, RCTs provide better evidence than observational studies but it is not true that RCTs always beat other forms of evidence. Many RCTs will tout statistical significance with a marginal success for the primary outcome measure but fail to demonstrate any clinical significance.

Mechanistic reasoning is inferences about a treatment’s probable efficacy based on an understanding of a cause-effect relationship. In some instances, we have reason to believe that we understand the causal mechanisms; at the very least the success in patient outcomes leads us to believe this is the case. In other instances, the causal mechanisms are unknown or so complex that there are gaps in our knowledge and little confidence in intervention. Where the mechanisms are well understood and there are no gaps in our knowledge, mechanistic reasoning certainly contributes to the total evidence, but by itself, it remains low in the hierarchies. Howick writes: “many lives would have been saved had the requirement for mechanistic reasoning been dropped in cases where we had evidence from high-quality comparative clinical studies” (136). He lists cases in which mechanistic reasoning led to the adoption of therapies that were either useless or harmful. These strongly suggest skepticism about therapeutic claims without support from high-quality evidence from clinical studies (154-56). Howick concludes that high-quality mechanistic reasoning should be weighed alongside results from comparative clinical studies since hypotheses supported by both are less likely to be spurious than hypotheses supported by one type of evidence (135-36).

When Howick turns his attention to expert judgment, it is clear why this form of evidence either remains at the bottom of the hierarchies or is excluded altogether. Reverence for experts lionized by the profession has led to the retention of therapies that are either harmful or useless. Moreover, all clinicians regard themselves as better than average when evidence from studies demonstrates otherwise. Nonetheless, there is a role for expert judgment of skilled clinicians when it comes to knowledge of how to respond to the individual circumstances and values of the patient using the best research evidence (178).

As a bare, abstract structure without regard to the merits and demerits of particular studies, mechanistic reasoning, or expert opinion, evidence-based medicine is therefore inadequate as a guide to clinical practice. One sort of evidence has to be considered within the totality of evidence to determine whether a medical intervention is likely to have clinically relevant benefits.

One of the main obstacles to achieving the ideal of evidence-based medicine is only briefly discussed in the conclusion of Howick’s book, namely, the proverbial fox guarding the henhouse—i.e., the great majority of RCTs are conducted by industry in partnerships with academic physicians. This is perhaps because the problem is deeply practical and political rather than philosophical. Howick draws attention to the fact that industry-sponsored trials are more likely to show positive results than non-industry funded trials (189-191). Due to the intensely competitive profit motive of marketing drugs and medical devices, the industry-sponsored RCTs have become notorious for misrepresentation of the efficacy and safety results. A good example of this was revealed in the manipulation of data to downplay safety results and ‘hide dead bodies’ (statistically speaking) in the clinical trials of Merck’s rofecoxib (Vioxx), which is estimated to have caused up to 120,000 cardiovascular events in the United States, including 40,000 to 60,000 that were fatal.

Prescribing physicians who are well aware of this problem are rightly skeptical about much of what passes for medical knowledge from RCTs, observational studies and respected authorities, i.e., ‘key opinion leaders,’ hired as product champions for the drug companies. Since physicians and researchers are never in position to know which trials are reported honestly and which are infected with statistical spin and blatant misreporting of outcomes, all bets are off regarding the reliability of evidence-based medicine. Where we do get some insight into the extent of the problem is from government inquiries and plaintiff’s lawsuits, but what comes to the surface in the public domain is only the tip of the iceberg. Thousands of medical journal articles reporting the results of industry RCTs cited over and over again remain unchallenged and when the very few subjected to re-analysis are proven to be fraudulent, editors of the journals and their owners refuse retraction.

Howick’s The Philosophy of Evidence-Based Medicine is valuable for the clear and cogent case that he presents for understanding the problems of evidence-based medicine and its solutions. Insofar as his primary goal is a critical evaluation of evidence-based medicine, Howick makes no attempt to explain where in the philosophical spectrum he stands regarding problems of confirmation or falsification of hypotheses or the all-important matter of how the paradigm of evidence-based medicine constitutes an advance, if indeed it does, in the progress of medical science. These issues remain for a more comprehensive philosophical investigation.

Mari Mikkola identifies three primary forms of social injustice—oppression, domination, and discrimination—and asks what makes them wrong. She argues that feminist philosophy has thus far focused heavily on gender as a lens or anchor through which to understand and respond to injustice. In Mikkola’s view, this orientation around gender (and what she terms “the gender controversy”) is limiting feminist philosophers’ theoretical engagement with the roots of injustice. To remedy this problem, she builds a case for moving toward a more broadly humanist conception of injustice. The humanist feminism that she puts forth centers dehumanization as a way to theorize injustice; dehumanization, for Mikkola, is the very foundation of injustice.

Following an introductory chapter that frames Mikkola’s approach and argument, the book is divided into two parts. The first part of the book is dedicated to articulating Mikkola’s argument for moving beyond the “gender controversy” in feminist philosophy. She explains that the perspectives debated in the gender controversy produce two kinds of puzzles: one semantic, the other ontological. The semantic puzzle asks: “Given that ordinary language users tend not to distinguish sex and gender (treating ‘woman’ largely as a sex term, or a mixture of social and biological features), what precisely are feminists talking about when they talk about ‘women’? What are the necessary and sufficient conditions that the concept woman encodes, if any such conditions exist to begin with?” (28). The ontological puzzle, by contrast, is concerned with: “How should we understand the category of women that is meant to undergird feminist political solidarity, if there are no necessary and sufficient conceptual conditions underlying our gender talk? Do women make up a genuine kind? […] What kinds of entities are gender and sex anyway?” (28).

Chapter 2 reviews aspects of how gender has been and is currently debated by feminist scholars. Mikkola articulates foundational feminist theorizations of the sex/gender distinction, the problem of biological determinism in thinking about sex and gender, and the social construction of gender. Core to this chapter’s exploration of the sex/gender debate is the problem that defining sex and/or gender relies on women sharing some common features that identify them as women and define their objectification as women. This poses a problem because not all women are equitably incorporated into this category; other vectors of perceived difference (like race, ethnicity, class) shape how women experience and define what it means to be “woman.” Thus, she reviews how a thicker and more inclusive definition of womanhood has been advocated through an intersectional approach to feminist politics and theory.

In chapters 3 and 4, Mikkola details nominalist and realist responses to what she terms the semantic and ontological puzzles of the gender controversy. Chapter 3 explains the gender nominalist position that “denies that there is some normatively and ethically significant feature that women qua women share; still, it holds that there is something that unifies women’s social kind, which is normatively significant” (46). In Mikkola’s view, nominalism lacks enough boundaries of what defines woman to effectively enact a feminist politics, while still maintaining woman as a category that likely will, in fact, slip into defining particular features of womanhood. Gender realism is explained in chapter 4 as perspectives that “hold that there is something women as women share, and this ‘something’ unifies their social kind” (71). The problems Mikkola identifies in both the gender realist and nominalist perspectives are that ideas about gender are far from unified (i.e., a single conception of what it means to be woman is impossible to achieve), they tend to be exclusionary (i.e., including only certain people in the category of womanhood), and there is limited potential for political transformation in these formulations.

Chapter 5 argues that semantic and ontological issues in understanding gender “are not as pressing as feminists make them out to be;” indeed, Mikkola writes: “I contend that we need not know ‘what it is to be a woman’ or to define woman in order to identify and explain gendered social inequalities or in order to say why patriarchy damages women” (105). Semantically, she argues that the way ordinary language users deploy the term woman is sufficient for identifying ‘women’s type’ (110). Ontologically, Mikkola suggests abandoning the sex/gender distinction to interrogate the foundational ontology on which this distinction rests. She advocates instead for an approach that frames the conversation through attention to “descriptive traits (traits of which there are ‘facts of the matter’) and evaluative norms (normative reactions to descriptive traits)” (117).

In moving beyond a preoccupation with the category woman and the gender controversy, it is not that Mikkola believes that women or gendered forms of discrimination, oppression, and domination are no longer important sites of social justice politics and theory; rather, she argues that sexism and gendered forms of injustice can be more effectively ameliorated not through an interrogation of the concept woman, but through the lens of dehumanization (what she argues is a more inclusive, humanist perspective). Thus, the second part of the book envisions what humanist feminism, organized around the concept of dehumanization, can do for feminist philosophy dedicated to a liberatory politics of responding to social injustice.

In chapter 6, Mikkola defines dehumanization in the following terms: “an act or a treatment is dehumanizing if and only if it is an indefensible setback to some of our legitimate human interests, where this setback constitutes a moral injury” (145). She then explores the case study of rape and how other philosophers have understood it to argue that rape is a dehumanizing act. She makes this argument based on the fact that rape violates fundamental interests for the well-being of human beings, and she lays out what, for her, are universal human interests, extending from the biological definition of human beings. In short, this chapter is about what makes certain injustices wrongful.

Chapter 7 explains three different forms of injustice—discrimination, domination, and oppression—and what constitutes each. Discrimination is about unjust “differential treatment” (192), domination is about unjust (and for Mikkola, dehumanizing) exercise of power over others (199), and oppression is a more complex process that, at its core, “has to do with unjust constraints” (204). Whereas chapter 7 focuses on the different forms injustice takes, chapter 8 explores the contours of social injustice. Mikkola identifies how injustice functions at the individual (attitudes and beliefs) and the institutional (social structures) levels (224). These contours of injustice involve understanding the effects of racism, sexism, trans*phobia, etc. and how they operate through the individual and structural levels.

In the final chapter, Mikkola points out that it would seem that logical responses to the three forms of injustice that she has identified would involve freedom, human flourishing, and equality. She articulates why freedom and human flourishing are not sufficient to uphold her conception of social justice, arguing for a conception of overcoming dehumanization that responds to the distinct features of social injustice (discrimination, domination, and oppression). In proposing a path forward for a humanist feminist approach to social justice, she posits that: “Equality of opportunity is the condition at the heart of nondehumanization” (239). In so doing, she offers up a framework on which further theorizing on normative ideas of social justice might be based.

There are two areas of the book that I felt could be enriched. The first is in Mikkola’s conception of the human. Shifting the focus away from woman to the human, Mikkola argues, “will avoid the current theoretical pitfalls” of a focus on woman as a category (149). But the human is no less fraught a category than woman and, I would argue, perhaps an even more troubling and difficult term to define and contain. In order to sidestep this complexity, she argues that, rather than trying to understand what constitutes the human or humanity through an approach that identifies certain capabilities or qualities or social processes, the human should be defined in strictly biological terms. “Members of such a kind,” she writes, “are of the homo sapiens sapiens species (anatomically modern humans); they are typically ‘featherless bipeds’ with certain dispositional cognitive capacities (like language and reasoning skills), which develop given the appropriate environmental conditions” (147).

Dehumanization, though, is a socio-political process, and put into action in the context of the human defined as the biological homo sapiens, there is a disjuncture in what these offer together. Dehumanization does not routinely strip a body of its biological taxonomy, so what is lost in dehumanizing acts is much more complicated, much more social. Mikkola’s interest in reducing the definition of human to a biological kind does not attend to the socially and politically contested notions of the human. I was left wanting a much more robust discussion of the human (since this is the category on which both humanism and dehumanization rely), and this enrichment could come from an engagement with postcolonial and Black feminist theories of the human (such as those articulated by Frantz Fanon, Sylvia Wynter, Alexander Weheliye, Hortense Spillers, or Katherine McKittrick). Coming out of these literatures are complex understandings of the human as a deeply contested category whose boundaries have been drawn and redrawn through not just gendered logics, but deeply racialized ones; and these contestations extend to the racialized histories of taxonomic ordering and the biological sciences. Thus, I found that Mikkola’s conception of the human as homo sapiens flattens these histories and the fraught ways in which the human is and has been defined.

The second area of the book that left me troubled was in its entrenched humanism that precludes any inclusion of other-than-human life. Mikkola, in fact, anticipates this critique and includes one footnote (168-169) that explains her exclusion of nonhuman life by saying that other-than-human life does not warrant inclusion in “our moral communities.” As a feminist scholar dedicated to researching human and animal relations and thinking about the consequences of dehumanization in a multispecies context, I found Mikkola’s call for a renewed humanism—and her stark definition of human as homo sapiens—to be limited in what it can offer broader notions of injustice or how injustice works in profound and deleterious ways beyond the bodily confines of homo sapiens. Dehumanization, as a framework, necessarily maintains hierarchical categories of being: the human, subhuman, and nonhuman. To dehumanize is to strip a body of the things that make it count as human; to make it other; to render it less-than-human, subhuman, nonhuman. And this act of dehumanization relies on the maintenance of these hierarchical orderings; in order to dehumanize, there must be a ‘less than’ or ‘sub’ category in which to drive humans who are the subjects of violent acts. Maneesha Deckha (2010) argues that, in fact, it is the subhuman and the maintenance of these categories that enables violence and Othering to occur against certain lives; for her (and for me), it is imperative to challenge these very hierarchies. Thus, while I am interested in the interrogation and use of dehumanization as a frame for understanding and responding to injustice, I worry over what (or who) it entrenches, reaffirms, and excludes.

Dominic Wilkinson, a neonatal physician and medical ethicist, has written a searching, moving, and philosophically sophisticated book about the ethics of life and death decision making in the neonatal intensive care unit. Although I will devote much of this review to criticism, I want to say at the outset that Death or Disability represents interdisciplinary work at its very best. Wilkinson’s exposition is both rich in detail and uncompromising in its ethical analysis. He spares the reader none of the clinical, psychological, and moral complexities and uncertainties of the decisions made daily in the neonatal intensive care unit (NICU).

I especially recommend this book to moral philosophers and practical ethicists worried that their debates on issues like time-relative interests and non-identity are ingrown and academic. Wilkinson explains the relevance of these and other seemingly arcane issues to the real, wrenching decisions that parents, physicians, and the larger society must make about the treatment of newborns at risk of very severe impairment.

After briefly outlining the structure of the book and some of its complex arguments, I will focus on three of the few areas where Wilkinson’s thorough, painstaking analysis strikes me as incomplete: the role of impersonal considerations in decisions about continuing or ending the lives of impaired neonates; the implications of the time-relative interest account Wilkinson adopts for balancing potentially conflicting interests in the neonate’s survival; and the role of physicians in helping to make neonatal treatment decisions under the threshold framework Wilkinson proposes.

The book begins with two prologues about imagined visits to learn the fate of a sickly neonate: one to the Roman Temple of Carmentis in 30 AD, the other to The Carmentis Machine in 2030. These prologues are vivid and engaging, but a bit disorienting. They give the reader the impression that Wilkinson will be focused on the implications of prognostic technologies that enable physicians and parents to reliably predict a neonate’s development. But the book is not, or is much more than, an exercise in speculative bioethics. The second, longer half is devoted to decision making under the prognostic uncertainty that we will continue to face in the near future. Moreover, the first half focuses on (relative) certainty only about significant neonatal impairments – certainty that current physicians and parents can sometimes achieve. Wilkinson does not discuss the issues that would be raised by information about minor health conditions and nonmedical characteristics, which the Carmentis Machine would reveal. Those issues are interesting in their own right, but they would distract from his intense focus on the dilemmas posed by severely impaired neonates.

Wilkinson begins his analysis by explaining how the contemporary NICU forces painful decisions on parents and physicians: it keeps alive 23-28 week old neonates who would have previously died, but who face extremely severe physical and cognitive impairments once they leave the unit. He illustrates the difficulties with detailed accounts of real and composite cases, to which he refers back throughout the book. In chapter 2, he considers the prevailing standard for making those decisions: with reference to “the best interests of the child.” He questions how, or even whether, neonatal decision makers can assess those interests, or judge that a neonate will have a life “not worth living.” He argues that they make those judgments, albeit with an uncomfortable degree of speculation, by balancing the expected benefits and harms of the neonate’s continued life. But he departs from the best-interests standard in arguing that the interests of parents, siblings, and others should also be taken into account.

Chapter 3 argues that impersonal considerations, concerning the effect of a decision about neonatal treatment on aggregate well-being, do not have a significant role to play in making those decisions. This chapter raises a number of philosophically interesting claims that I discuss below. Chapter 4 concludes Part I with a richly detailed review of the potentially conflicting personal interests that are most directly implicated in neonatal treatment decisions: those of parents, siblings, and the child itself. Wilkinson defends the controversial claim that the neonate’s own interests should be discounted by its limited psychological continuity with its future self – a claim whose implications I discuss below.

Part II, starting with Chapter 5, introduces the manifold uncertainties that physicians and patients confront in the NICU, not all of which can be resolved by improved predictive technologies. I found this part of the book the most difficult, because it presents complex normative arguments that are resolved in part by the critical examination of empirical research. Chapter 5 reviews the evidence we have on the prognosis for severely impaired neonates. Wilkinson enumerates the factors that limit the inferences we can draw from existing data. For example, most studies count the deaths of infants for whom treatment was withdrawn, raising the acute problem of self-fulfilling prophecies. But counting only those neonates for whom treatment was extended may overrepresent the relatively healthy; those for whom treatment would have seemed more promising. Yet the sickest neonates also may be overrepresented in the leading studies, which come from specialized care centers. Some readers may find this methodological rigor daunting; there were times I struggled to see the forest for the trees. Perhaps the most accessible and important section of the chapter deals with the difficulties of quality-of-life assessment. These assessment blur medical prognosis with the normative evaluation of medically-challenged lives. Health professionals consistently give lower quality of life estimates than families (and much lower than those given by disabled individuals able to judge themselves); this may reflect their professional emphasis on health more than their superior knowledge.

Chapter 6 discusses ways of managing this uncertainty, focusing on the strategy of obtaining greater knowledge by prolonging treatment. This strategy raises a concern about the moral risk of extending treatment beyond the so-called “window of opportunity,” when the neonate’s survival is dependent on medical technology. Wilkinson argues for greater parental discretion on both ends: early withdrawal will often be justified given the evidence parents already have and the limited prognostic gain likely from continued treatment; parents may decide to let the child die past the “window” if the prognosis remains grim, by removing nutrition and hydration – a withdrawal that Wilkinson finds no more problematic in principle than removing a ventilator. Chapter 7 revisits the interests at stake in neonatal treatment decisions in light of these uncertainties. Its highlight is an original and highly sensitive account of the complex relationship between the interests of the neonate and its parents.

The book concludes with a careful proposal in chapter 8 for decision making under this prognostic and moral uncertainty. Wilkinson offers a two-threshold framework that carves out a space for parental discretion, between cases where the neonate’s dire prospects make continued life-support unacceptable and cases where its decent prospects make withdrawal unacceptable. He gives examples of cases that arguably fall within this “grey zone,” while acknowledging the daunting conceptual and practical problems in setting the thresholds. He finds grounds for optimism in the apparent consensus among an array of professional groups on guidelines. Less encouraging is his report of wide variability among individual physicians on specific cases, a finding that suggests that the consensus among groups may be largely verbal. In setting the thresholds, Wilkinson says very little about the impersonal considerations he discussed earlier, as well as the (ultimately personal) interests of the larger society in the cost of neonatal care. Although he has been criticized for his neglect of social costs (Foster 2013), that omission will be welcomed by those, like me, who deny that physicians, let alone parents, should engage in bedside rationing.

Wilkinson is particularly good at anticipating questions and objections; most of mine were thoughtfully addressed soon after they arose. There are, however, a few significant issues that could have benefited from further discussion:

1. In his analysis of the moral reasons for “replacing” a severely disabled neonate with a healthy child, Wilkinson does not deny that impersonal considerations have moral force; he merely argues that they provide only weak moral reasons for replacement, which can easily be outweighed even by fairly minor parental interests. His argument is, roughly, that 1) in most cases, the impersonal gain from replacing a less with a more healthy child will be smaller than the gain from having a more healthy child rather than none; 2) The gain in impersonal good from the latter is not enough to give parents a strong moral reason to have a healthy child; so 3) the moral reason parents have to replace a less with a more health child will be even weaker.

Although I doubt that impersonal considerations have any moral force, a proponent of replacement could respond by challenging a key assumption in Wilkinson’s argument: that if there is a moral reason to have a more rather than less healthy child, there is a moral reason to have a healthy child rather than no child. Johann Frick (2014) has recently argued that selection among possible children is a conditional duty, analogous to promise-keeping. One has no duty to make promises, only a duty to fulfill them if one has made them. Making a promise subjects the agent to a standard that would not otherwise apply to her. Similarly, one has no duty to have children. But, Frick contends, if one decides to have children, one has a duty to have the child with the happiest possible life; not only to make one’s child happy, but to select the child with the greatest potential for happiness. One needn’t accept this as the applicable standard for prospective parents – I emphatically don’t – to accept Frick’s more general point that whatever the correct standard is, it applies only conditionally.

In the context of procreation, Frick’s analysis challenges Wilkinson’s claim that it is inconsistent to acknowledge a moral reason to pick the happier or healthier child but not a moral reason to select either over no child. Even if this inference is blocked, however, Wilkinson could plausibly argue that the applicable standard is different for replacement than conception. It would be implausible to claim that parents had a strong moral reason to continue replacing neonates until they obtained the best one they could reasonably expect. But Wilkinson could not set a less demanding standard based on a comparison with the impersonal gains expected from conception – that comparison would simply be irrelevant.

More broadly, Wilkinson does not offer a decisive verdict on the scope, weight, and role of impersonal considerations. He shares the widely-held intuition that a world containing multitudes of people with lives just barely worth living would be worse than one with fewer, better-off people, even if the former had greater aggregate well-being. Moreover, he denies this this “repugnant conclusion” can be avoided by limiting impersonal considerations to “same number” choices, in which either choice will result in the same number of people ever existing. Wilkinson finds this limitation not only ad hoc but unhelpful, since replacement results in a different number of people ever existing. Yet at the same time, he recognizes the intuitive force of impersonal considerations in “substitution” cases, where prospective parents must choose between having a worse-off child now or waiting to have a better-off child later. Wilkinson, then, is unwilling to deny impersonal considerations some role in the NICU, even if he concludes that this role will usually be insubstantial. They remain as strangers at the neonates’ bedside, along with the personal interests of the neonate, parents, siblings, and others that Wilkinson so fully acknowledges.

2. The relevance and weight of impersonal considerations are left uncertain not only in replacement, but in treatment decisions where replacement is not at issue. Even if impersonal considerations lack great weight, they do not need much to serve as a thumb on the scales in close cases. This poses an especially significant challenge for Wilkinson, since he gives comparatively little weight to the interest of neonates in continued existence. According to Jeff McMahan’s Time-Relative Interest Account (TRIA) (2002), which Wilkinson adopts, a being’s interest in its future depends on the psychological connections it has with that future, connections that are very tenuous for a neonate. No matter how rich and rewarding its life is expected to be, a neonate’s time-relative interest in continuing it will be fairly slight. Wilkinson denies that this discounting will license treatment withdrawal in most cases, but his denial relies to an uncomfortable extent on the interests most parents have in the neonate’s survival, especially if its impairments are only moderate or mild. Not only are those interests highly contingent and variable, they may be outweighed in close cases by impersonal considerations – a prospect Wilkinson fails to address in his discussion of competing interests.

Even if parents are reluctant to withdraw support from an impaired neonate, an impersonal assessment of their interests may favor withdrawal. They may be significantly better-off in the long run without the expense and stress of raising a severely impaired child; they may be fully aware of this despite opposing withdrawal. (I agree with Wilkinson both that the challenges of raising a severely impaired child are often exaggerated, and that they can be oppressive or overwhelming for some parents.) Their willingness to sacrifice their own well-being arguably takes their personal interests off the scale, but it may have little or no relevance for the impersonal calculus. Even taking account of grief and guilt, their net well-being might be substantially increased if treatment is withdrawn. That gain in well-being counts impersonally, and it could easily outweigh the neonate’s highly discounted interest in survival. Allowing impersonal considerations any role in the NICU complicates, and arguably distorts, the formidable task of balancing the interests of actual persons– the child, parents, siblings, and the larger society.

3. I want to conclude by highlighting one of the difficulties in implementing the threshold framework that Wilkinson develops: the challenge to the physician’s traditional patient-centered role. Under that framework, it is not clear whether the physician can or should remain an advocate solely for the child’s interests. That role would require physicians to advocate withdrawal or continuation in the “grey zone,” depending on what they saw as in the neonate’s interest, against parents who had come to the opposite conclusion. Given the well-documented pessimism of physicians about prognosis and quality of life, their advocacy would likely reflect and reinforce the asymmetry between let-die and keep-alive decisions defended by Wilkinson, favoring withdrawal in close cases.

But there is a price for the clarity about potentially-conflicting interests promoted by such physician advocacy. Parents faced with agonizing decisions about whether to let-die or keep alive a very severely impaired neonate may often conflate their own interests with those of the child, a conflation facilitated by the extensive overlap in their interests. Clearly distinguishing the interests that do not overlap might improve the quality of parental decision making in some ways, but it might also have a substantial cost for parents who choose to withdraw support based in part on their non-overlapping interests. In cases where the physician believes it is in the child’s interest to continue living despite the heavy burdens for the parents, her well-intentioned advocacy to that effect will throw their “selfish” interests into sharp relief. I suspect it is much easier for parents to rationalize withdrawal decisions as made exclusively in the child’s interests than to acknowledge that their own interests tipped the balance. This may be self-deception, but it would be problematic for physicians to deny them this small mercy.

To conclude, this is an impressively serious, wise, and humane book. If there is a consequentialist aspect to Wilkinson’s analysis, it is not found in appeals to aggregate welfare or the impersonal good to resolve difficult questions. Rather, it is reflected in a deep, informed concern for all of the interests implicated in decisions about severely impaired neonates. Wilkinson’s perspective is encompassing, not impersonal; he comes close to the ideal of an empathic but unsentimental Impartial Observer, displaying a rare capacity to appreciate the multiplicity of interests and values that must be taken into account in making life-and-death decisions about severely impaired neonates.

David WassermanDepartment of Bioethics
National Institutes of Health
Bethesda, MD, USA

Disclaimer: The views expressed are the author’s own. They do not represent the position or policy of the National Institutes of Health, U.S. Public Health Service, or the Department of Health and Human Services.

REFERENCES

Foster, Charles. 2013. “Review of Death or Disability: The Carmentis Machine and Decision-Making for Critically Ill Children.” European Journal of Health Law 20: 532-539.

Frick, Johann David. 2014. “‘Making People Happy, Not Making Happy People’: A Defense of the Asymmetry Intuition in Population Ethics.” PhD diss., Harvard.

McMahan, Jeff. 2002. The Ethics of Killing: Problems at the Margins of Life. New York: Oxford University Press.

Professor Elizabeth Barnes has produced a tightly and carefully reasoned philosophical examination of the significance of disability. It provides a clear defense of certain core principles of the disability rights movement in contrast to the many professional philosophers (those which I will term ‘mainstream bioethicists’) who consider that movement to be ill-conceived. An example of this tradition can be seen in the volume From Choice to Chance: Genetics and Justice, coauthored by four of the most prominent bioethicists of the turn of the century (Buchanan, Brock, Daniels, & Wikler 2000). (For discussion see Amundson & Tresky 2007, 2008.) I confess to the prejudice implied by my label of ‘mainstream bioethicists’ as those beset by the prejudice of ableism. The late Adrienne Asch considered herself a mainstream bioethicist even though her progressive views of disability were rare among her colleagues.

Disability rights is a serious civil rights movement, equal in significance to gay rights, feminism, resistance against discrimination on the basis of ‘race,’ and a number of other such movements. Just as earlier generations of philosophers assumed the legitimacy of the social prejudices of their own times, mainstream bioethicists have assumed the correctness of prevailing assumptions about disability. In this tradition, disabilities are conceptualized as inimical to well-being, they essentially involve suffering, and any civic ameliorations of the problems of disability are seen to result only in slight improvements to the essentially low quality of a disabled life. Barnes argues the contrary. Disabilities should be conceived as mere differences, not bad differences. Her neutral model of disability comports with a great deal of testimony from disabled people themselves. But such testimony is vulnerable to principled dismissals from their philosophical critics (few of them disabled). Barnes proceeds to argue against those dismissals, concluding that they are cases of testimonial injustice. I will sketch aspects of these two conclusions: first her neutral model of disability, and second her defense of the contrary testimony of disabled individuals against dismissal.

The Value-Neutral Model. Barnes acknowledges that individual cases of disability often co-occur with lowered well-being. However she argues that it is a mistake to conclude that disability is itself the cause of lowered well-being. Arguments in favor of the conceptual linkage between disability and lowered life quality are common in the literature. For example: Disability is abnormal function, normal life opportunities require normal function, sub-normal life opportunities therefore imply reduced well-being, which proves that disability implies reduced well-being. (This argument is reconstructed from Buchanan et al. 2000.) How does Barnes refute this inference? She begins by distinguishing between local ‘bads’ and global ‘bads.’ Global bads are things that are bad for you on the whole, largely without respect to your situation. Local bads are bad for you only with respect to certain contexts or situations. This is nearly all she needs to reveal the value-neutrality of disability. Using a list of individual cases of ‘goods’ and ‘bads’ she shows (a) that many things that are highly valued by individuals also have serious ‘bads’ associated with them and (b) that many people who have significant disabilities also find important ‘goods’ associated with their disabling conditions. To weaken our assumptions of the bad-making properties of disabilities, Barnes cites some important examples of conditions that have recently been socially reclassified from ‘assumed to be bad-making’ to ‘assumed to be neutral.’ One of these is gayness. She reports gayness to be a neutral trait, even though it can surely be associated with very low well-being when it occurs in a social context that is heavily prejudiced against gayness. Our own society has only recently come to hold that gayness is a neutral trait. Not long ago, and certainly within my lifetime, gayness was classified as a psychiatric illness by medical authorities and deemed (by typical Americans) to cause very low well-being. We must notice that majority agreement with Barnes’s assessment that gayness is a neutral trait is not necessary for the strength of her argument. Even if her view about gayness (which I share) is not shared with the general public, it is surely shared among the majority of liberal, college educated Americans. (The recent election has shaken my confidence in guessing the opinions of my fellow countrypersons.) The important point is not that academics are correct in our views, but that we have changed our views with respect to gayness in recent decades. Barnes offers a corresponding argument with respect to biological sex, and claims that being a man is neutral with respect to well-being. This view was rejected not only by Aristotle, but by many others (predominantly men, the sex that dominates the historical record) well into the 20th century. (I was shaken by Barnes’s hypothetical discussion of how the lives of men might be assumed to be much lower in quality than those of women [131]. I would have been more comfortable if she had stuck with social prejudices that matched my own.) Even if we liberals relinquish our claim to objective correctness, Barnes’s point stands. Earlier assumptions about how traits influence well-being have changed. The assumption about disability might change also. We must not assume the contrary, especially if evidence is against it.

Taking Their Word for It. What is the evidence that disability is neutral with respect to well-being? Some of it comes from questionnaires which clearly indicate that the average self-assessed well-being of disabled individuals is only slightly lower than that of non-disabled individuals. Published autobiographical reports often reflect similar valuation. One of Barnes’s many examples from this literature is Dostoevsky, who we learn had a serious form of epilepsy that strongly affected him throughout his adult life. Nevertheless, Dostoevsky valued his epilepsy highly because the special experiences that accompanied seizures, stating that “all you healthy people don’t even suspect what happiness is” (quoted in Barnes 2016, 109).

Nevertheless, mainstream bioethicists continue to believe that disabled people have a much lower level of well-being than nondisabled people. They do not change their opinions in the face of this apparent counterevidence. Instead they come up with reasons to dismiss the counterevidence. This is my second topic: Barnes’s discussion of the grounds on which mainstream bioethicists dismiss the disability-positive testimony of disabled people.

Disabled testimony is dismissed by likening it to cases like Stockholm Syndrome (in which hostages come to sympathize with their captors) or abused spouses who refuse to testify against their abusive partners out of a belief (that we presume to be irrational) that they are better off with the abuser than without him or her. The philosophical details of this problem are too complex to even summarize here, but Barnes does a fine job of explaining why dismissing the testimony of disabled people about their own well-being does not count as a liberation of victims from their delusions, as it would be for Stockholm Syndrome hostages or agreeable abused spouses. Instead it is an illegitimate dismissal of legitimate testimony. Barnes labels these dismissals as ‘testimonial injustice’ following philosopher Miranda Fricker (Fricker 2007). Disability studies authors (including your modest commentator) have rejected this kind of dismissal with similar purposes as Barnes. Unlike most other disability studies writers, Barnes has a close and detailed understanding of the theoretical background that underlies the dismissal. Her detailed discussion is welcome.

Overview. Barnes’s careful and concentrated philosophical discussions may not be attractive to some disability studies authors, who favor a more socially oriented approach to the problems of disability. She does little to position her writings in the context of other disability studies authors, except those that give autobiographical reports on their own well-being. A clearer acknowledgement of those relationships would have been useful. The book’s close philosophical focus will endear it neither to all disability rights advocates (it will seem curiously bloodless to some) nor, at first glance, to all philosophers (whose prejudices are being challenged). She reports that her entire book is aimed at providing a justification for the “disability pride” movement. I do not share that particular goal. It seems to me that the disability rights movement requires ‘pride’ only as a rhetorical flourish, as other ethnic movements have used it. But the arguments are especially valuable within the philosophical community. The neutral model of disability and other products of Barnes’s analysis are independently important. I was once told that one of my naïve efforts at explaining disability rights to philosophers was the first such published account (Amundson 1992). Since then the growth of interest in disability among philosophers has been impressive, though not overwhelming. It is time that close analytic attention was given to these problems, and Barnes’s book is a promising contribution.

David Shoemaker’s highly innovative and intricately argued new book draws on much of his previous work together with substantial original material to form a detailed and cohesive treatment of responsibility. The book is engaging, crisp, and admirably clear. It is marvelously ambitious in its strategy and framework, engagement with multiple literatures, and decidedly novel approach to Strawsonian theory. Moral philosophers, psychologists, clinicians and practitioners, and anyone who has ever wondered about “marginal agents” – people with dementia, autism, (manic-)depression, OCD, and psychopaths – will find much to entice them in this thorough and accessible treatise.

Shoemaker’s starting point – the phenomenon he aims to explain – is the observation that many of us feel a certain ambivalence toward marginal agents of the sort mentioned above. When we interact with or read case studies of marginal agents, we feel a “profound unease,” which Shoemaker diagnoses as caused by the fact that “these agents seem worthy of some responsibility responses but not others, which suggests that they are responsible in some ways but not in others” (3). This is the foundational premise of the entire book. For Shoemaker, responsibility responses include but are not at all limited to the standard praise, blame, and resentment; admiration and contempt, approval and disapproval, pride and shame, anger and regret are all brought in under this unusually wide conception of responsibility responses (a point I’ll return to in my final remarks). The idea is that psychopaths may deserve contempt but not anger, patients with dementia may deserve admiration but not resentment, and so on and so forth.

Starting from responsibility responses puts Shoemaker squarely in the Strawsonian camp of moral responsibility theorists. Put in the simplest of nutshells, P.F. Strawson’s revolutionizing argument for sidestepping the free will problem in “Freedom and Resentment” was that we should stop thinking of responsibility responses as only justified by certain metaphysical facts, i.e., by the fact that we are agents with free will, and instead think of our responsibility responses as justified by their role in (unavoidably necessary but also intrinsically valuable) social practices of caring about and responding to others’ manifestations of goodwill or ill will toward us (Strawson 1962). In Part I, Shoemaker introduces three main modifications[1] to Strawson’s view. The first is that Shoemaker draws a tripartite distinction amongst the “attitudes and intentions towards us” or the “quality of others’ wills towards us” that Strawson takes to be the object of reactive attitudes (Strawson 1962 48, 56); he distinguishes between the quality of others’ character, the quality of others’ judgment, and the quality of others’ regard for us. The second is an account of responsibility responses in terms of “sentiments” (along the lines of metaethical and aesthetic sentimentalism), where sentiments are dispositions to feel a special type of emotions that are culturally universal and recalcitrant to judgment.[2] The third, following closely from the second, is slipped into an unobtrusive argument that if the appropriateness of our responsibility responses are not justified by metaphysical facts then “it must be a matter merely of how the responses somehow fit with their objects” (19). In other words, Shoemaker understands the justification of responsibility responses in terms of fittingness. Responsibility responses are justified when they are fitting to their objects, just as emotional and aesthetic responses are appropriate when they are fitting to their objects.[3]

Shoemaker thus identifies three paradigmatic pairs of sentiments (and other related emotions) that correspond to the three different objects of our responsibility responses: agential disdain and admiration (along with contempt, abhorrence, awe, veneration, etc.) are the fitting positive and negative responses to good and bad character; agential regret and pride (etc.) are the fitting responses to good and bad judgment; and agential anger and gratitude (etc.) to good and bad regard. These correspond to what Shoemaker calls responsibility as attributability (directed at character), answerability (directed at judgment), and accountability (directed at regard). Part I of the book is devoted to laying out this theory and defending the distinctiveness of each of the three types of responsibility.

In Part II, Shoemaker shows how this tripartite account accommodates our ambivalent responses to marginal agents; in each case, he argues that the condition in question disrupts some of the capacities or psychic elements required for one form of responsibility, but leaves intact others required for other forms of responsibility. People with depression have mitigated attributability for their actions, because the depression has interfered with the cares and commitments that constitute a person’s character (or “deep self”), but they may still be capable of responding to reasons and experiencing empathy in the ways required for answerability and attributability. Psychopaths lack the capacities for experiencing empathy (or have severely mitigated capacities to do so) required to sustain properly moral regard for others, so they are exempt from accountability, but they still have the capacities for character and judgment[4] that are required for attributability and answerability. And people with mild intellectual disabilities are exempt from (or have mitigated) answerability, because they lack the cognitive and adaptive capacities – reasoning, planning, learning – that are required for properly reasons-responsive evaluative judgment; but they may still have cares and commitments that constitute their distinctive selves and they may still be capable of empathy, especially for those with whom they have close relationships, in such a way as to preserve their attributability and accountability. Shoemaker provides similar accounts for people with mania, scrupulosity,[5] high-functioning autism, dementia, and poor formative circumstances (i.e., morally deprived childhoods), demonstrating impressive mastery of the empirical literature around each of these marginal cases. The book really shines when Shoemaker draws on the resources of his tripartite theory to make illuminating proposals for further empirical and clinical investigation. He writes: “[O]nce we move beyond the deeply entrenched all-or-nothing model of responsibility, the tripartite theory opens us up to a new, nuanced set of tools for both those who treat and those who suffer from (at least some of) these disorders” (145). In short, a more fine-grained moral theory can help us better conceptualize complex psychological phenomena, while in the other direction, diving into real-life details prompts the development of more sophisticated moral theory.

In the remainder of this review, however, I will raise three worries for the project: one regarding the general strategy, and two regarding Shoemaker’s sentimentalist take on Strawsonian theory. My first worry is that, insofar as Shoemaker claims that the puzzle to be solved is the fact of our ambivalent responses to marginal agents, it is not clear that the tripartite theory is really necessary. Shoemaker says very little to characterize the phenomenon or what he actually means by “ambivalent” responses, other than that the “unease of ambivalence” is not the unease of uncertainty, before diagnosing it in (the already quite theory-laden) terms of feeling that agents merit some responsibility responses rather than others (3). There might be alternative ways of explaining this ambivalence, however. It might not be genuine ambivalence, for instance, if our responsibility responses are simply keyed to certain facets of the cases which feel warranted or not depending on whether those facets are made salient at a given moment or not. In other words, like optical illusions that flip from duck to rabbit, young girl to old woman, depending on which cues we focus on – but where the picture is either of a duck or a rabbit, and not a part-duck/part-rabbit – perhaps, too, a marginal agent could be responsible when her case is viewed under a certain light, and not responsible under a different light, but it not be the case that under a single description[6] some responsibility responses are appropriate while others are not.

Or, to take another visual metaphor inspired by Shoemaker’s own discussion of “local blindnesses” whereby an agent may be responsive to reasons only in some domains but not others (82), perhaps we could think of our ambivalent responses as picking up on domain-specific gaps in more unified responsibility-conferring capacities that are overall intact. For example, on accounts that would deny Shoemaker’s attributability-answerability distinction,[7] it might be that a marginal agent is a responsible agent overall for her actions and attitudes in virtue of how it is possible for them to flow from her evaluative judgment, but that she lacks responsibility for specific actions and attitudes flowing from certain judgment “blindnesses,” or domains over which her capacity for judgment is blocked or lacking. Thus a person with depression might still count as a responsible agent in virtue of the fact that her evaluative judgment is intact overall, as evidenced by the fact that she manages to sustain quite a few minimally requisite actions, e.g., feeding herself, keeping her job; but there are large and important swaths of a full human life, e.g., her relationships, her activities, in which the operation of her evaluative judgment is too distorted for her to be responsible for them. This last observation might be related to the fact that Shoemaker claims to be giving an account of responsible agency, rather than responsibility for particular actions, which suggests, finally, that some of our ambivalence toward marginal agents might also be handled by distinguishing between how we feel toward them as agents versus how we feel toward them as agents in light of specific instances of behavior.

I suspect, however, that the puzzle of ambivalent responsibility responses might be (at least somewhat) less central to the motivations behind the tripartite theory than suggested, and we could simply think of marginal agents as exemplary case studies for illustrating its power. This brings me to my second set of worries, however, which is that the trifold sentimentalist strategy and framework – marvelously conceived though it is – may not be enough to sway those who prefer unified accounts of responsibility that can still save the phenomena. The costs of relatively minor or esoteric counterexamples may not outweigh the benefits of simplicity. Out-of-character actions and whims,[8] for instance, which Shoemaker takes to be instances of answerability without attributability (59, 83), seem to me still attributable to agents as manifestations of some kind of character trait, even if not the obvious ones: a wandering mind, an active curiosity, sublimated anxieties and desires, a love of spontaneity, and so on. (This move would be akin to one Shoemaker makes in his own analysis of scrupulosity, according to which such agents’ general “moral orientation” and perfectionist stance renders many of their thoughts and attitudes still properly attributable to them.) Or they may manifest pro tanto evaluative judgments rather than all-things-considered evaluative judgments[9] about the worth of some action.

I also found myself worried at times about proposals that, while innovative, struck me as potentially ad hoc or insufficiently grounded in deeper justification. If debates about the deep self have centered around Platonic versus Humean accounts, for instance, is it a satisfying resolution to simply combine them into an ecumenical position, without further diagnosis, explanation, or motivation? If the dominant philosophical and psychological view is that anger fundamentally involves revenge, is it enough to point to the existence of some cases in which people feel frustrated if they cannot communicate to the objects of their anger that “This is for what you did to me!” (105)? (For surely we can imagine agents whose anger leads them to want simply to annihilate and destroy the objects of their anger, or whose anger is satisfied when revenge can be carried out anonymously such that their objects “never even knew what hit them”.) Is it fair game to simply declare that we have “empathic control” when identifying with others’ perspectives leads us to certain kinds of emotional or reasons-responsiveness, such that these are “up to us” in the way that things over which we have voluntary control or rational control are up to us? (For the latter have been understood as “up to us” because they derive from our wills or our evaluative judgment, which have been argued to be constitutive of moral agency; but such an argument has yet to be made for empathic capacities.)

Finally, there were some moves that seemed to betray some artificiality in the tripartite taxonomy of sentiments. In the case of admiration (one of the emotional syndrome pair for attributability), for instance, Shoemaker restricts the sentiment to agential admiration, setting aside cases in which we admire non-agents, e.g., the Grand Canyon; but when it comes to finding the emotional syndrome pair for answerability, Shoemaker simply sets aside disappointment on the grounds that it is not restricted to agents. This leads him to adopt a first-personal emotional syndrome pair for answerability (pride-regret) that does not match the third-personal pairs for attributability and accountability. And although Shoemaker acknowledges that we may sometimes feel regret even when we absolutely do not manifest any flaw in evaluative judgment, he dismisses these as non-paradigmatic cases of regret which do not count as genuine responsibility responses. Of course, any theory – especially new and ambitious ones – will contain anomalies. But since Shoemaker’s job is to convince us that there really are three fundamental pairs of sentimentalist responsibility responses and since his work is otherwise so thoroughly grounded in empirical evidence, I am hopeful for more reason to think that the tripartite theory has successfully latched onto natural kinds in our actual practice rather than being a theoretical framework imposed from the armchair.

This brings me to my final worry, about the sentimentalist fittingness approach to justifying responsibility responses. In developing his tripartite theory, Shoemaker has broadened his responsibility responses beyond the responses of resentment and indignation on which other theorists have focused.[10] To be sure, Strawson himself does identify a wide range of reactive attitudes, including “gratitude, resentment, forgiveness, love, and hurt feelings” (49). But this is in the first stage of Strawson’s argument, in which he is pointing out the existence of reactive attitudes in general; the second stage of his argument is to explore whether an understanding of specific reactive attitudes can “bring us, if possible, nearer to a position of compromise in a more usual area of debate” (56), where the usual debate, of course, centers around “desert, responsibility, guilt, condemnation, and justice” and the problem of free will (64). Moreover Strawson is clear that he is interested primarily in moral responsibility,[11] that is, in the “concept of moral responsibility and of the practices of moral condemnation and punishment” (62). It is no accident that desert, condemnation, justice, and above all free will – precisely those concepts that Shoemaker sets aside in his last chapter – are concepts that intimately involve concerns about fairness. Thus when Shoemaker declares that appeals to unfairness constitute “the wrong kind of reason,” since they are orthogonal to questions of whether some responsibility response is fitting to its target in the way that aesthetic responses are (201), this seems to me a significant deviation from the Strawsonian project. Even if it is (quasi-aesthetically) fitting to feel contempt toward a vicious agent, concerns about determinism and free will – Strawson’s target – arise only when we worry about whether it is morally appropriate for us to feel that way toward an agent who did not have, e.g., the (fair) opportunity to avoid becoming vicious. Similarly, when Shoemaker disavows the centrality and relevance of harsh treatment to responsibility, this seems to depart altogether from the Strawsonian starting point that begins with our practices of moral condemnation and punishment.

Shoemaker, of course, is aware of this difficulty, stating: “I want to insist on the crucial distinction (a distinction I believe has long been overlooked) between the fittingness of various sentimental responsibility responses and the appropriateness of harsh treatment of offenders” (223). I cannot help but suspect, however, that this final, insisted-upon distinction suggests that the fundamental distinction might hold between just two faces or concepts of responsibility, as defended (in different ways) by theorists such as Gary Watson (2004), Tim Scanlon (1998), Iris Marion Young (2011), and myself. If I am right about this, then Shoemaker will have offered us an exceptionally elegant and richly-detailed Strawson-inspired theory of the first (aretaic or attributability) concept of responsibility, while more or less setting aside the second (substantive or accountability) concept of responsibility with which Strawsonians typically concern themselves. But none of this detracts from the huge contribution that Shoemaker has achieved in this book with his exciting and fruitful new framework for thinking about responsibility.

Robin ZhengYale-NUS College
Singapore

REFERENCES

Scanlon, Thomas. 1998. What e owe to each other. Cambridge: Belknap Press of Harvard University Press.

NOTES

[1] Or, depending on how invested one is in Strawsonian exegesis (the temptation of which I try, but perhaps not hard enough, to resist as far as possible in this review), three main interpretive extensions.

[2] The latter simply refers to the tendency of some emotions to remain even when certain beliefs that constitutively define that emotion are given up, e.g., continuing to fear a spider even after one has acquired reason to give up the belief that it is dangerous.

[3] This sort of fittingness view has been defended with regard to blame in particular; see, e.g., Arpaly (2002) and Hieronymi (2004).

[4] This is true, at least, for nonmoral judgments. But they may lack the capacity for moral judgments that require having moral regard for others, and hence lack answerability in these domains.

[5] A form of OCD involving obsessive thoughts about morality, e.g., that one has committed a moral wrong merely by imagining a certain event.

[6] Whether there is an objectively best way of describing the case might depend on deeper commitments about the nature of responsibility, e.g., whether responsibility is primarily a metaphysical or practical matter.

[7] The difference for Shoemaker consists primarily in the fact that answerability is limited to evaluative judgment, while attributability ranges more widely across commitments and cares that are distinct from or not grounded in specific judgments.

[8] This addresses the second of Shoemaker’s three arguments for the distinction between attributability and answerability. In response to the third counterexample of an agent who holds two conflicting attitudes that are singly unobjectionable but irrational when combined, a unified account theorist might endorse Smith’s (2012) reply and argue that what deserves criticism is not the irrationality of this configuration, but the irrationality of failing to take steps to alter the configuration once the conflict has become so salient. For most of us likely harbor at least some irrational configurations of conflicting attitudes (like contradictory beliefs) which are not worth the time or effort to resolve.

[9] A unified account theorist might use this to argue against Shoemaker’s first argument: cares and commitments might be grounded in pro tanto rather than all-things-considered judgments.

[10] See, most notably, Wallace’s (1994) arguments for narrowing the class of reactive attitudes to those which hold someone to an expectation, e.g., resentment, indignation, and guilt (25-33).

[11] More fully, Strawson writes: “The concepts we are concerned with are those of responsibility and guilt, qualified as ‘moral’, on the one hand— together with that of membership of a moral community; of demand, indignation, disapprobation and condemnation, qualified as ‘moral’, on the other hand—together with that of punishment” (62).

Becoming Human by Jennifer Greenwood is one of the most thought-provoking books on emotion and its expression I have read. At its core, it attempts to provide an account of the development of full human emotionality and in so doing argues the emotions are “transcranial.” Emotions are radically realized outside our nervous systems and beyond our skin. As children, we are functionally integrated affectively with our mothers; so much so that in a sense our emotions are not ours alone. Regardless of whether one agrees with her radical claims, it is a must-read for those interested in emotion and expression. In order appreciate the significance of this book, let me sketch its contents and raise a few criticisms.

Many, but certainly not all, psychologists and philosophers assume that there are basic emotions (BEs) and higher-cognitive emotions (HCEs). The former include fear, anger, disgust, happiness, surprise, and sadness; and the later include guilt, shame, and pride amongst others. BEs are thought of as natural kinds involving facial expression, homologous traits shared with non-human primates, specific brain structures, and stereotyped behaviors. HCEs differ in that they often do not have unique physiological profiles, facial expressions, dedicated brain regions, and culturally vary quite a bit. Greenwood argues that there are affective precursors that develop into BEs and HCEs. However, the distinction between BEs and HCEs lulls us into naïve views about nature and nurture, biology and culture. We have not taken their development from childhood as seriously as we should. Both develop through time.

Greenwood has us consider human infants. They are completely dependent on their caregiver who is usually their mother. They can cry and exhibit motor unrest to convey how things are going for them. Their emotional precursors are ostensive and expressive. They are ostensive insofar as they direct the attention of the mother to sources of displeasure and they are expressive insofar as they signal that displeasure. They are referentially opaque but through time become less so. Thus, these emotional precursors are natural signs which occur when proprioceptive and interoceptive thresholds have been crossed and help is needed. Crying and motor unrest are assistance-soliciting devices. Mothers are equipped with “intuitive parenting” skills by which they can identify what things are helpful and harmful to their child. They instinctually respond to the child’s stress and try to remove the sources of it. This also involves mimicry in speech and mirrored facial expressions of their child. These are assistance-producing devices. Through repeated interactions of these assistance-soliciting and assistance-providing devices, the child’s emotionality advances through functional integration with the mother. Not only do these interactions provide feelings of pleasure but also new neural machinery develops as the result of these dynamic interactions. There are complex causal interactions between child and mother, which scaffold the child’s emotions and their expression. It is also through the same mechanisms that language appears as well. “Motherese” helps the child to understand the boundaries between clauses and how to command, request, declare, and to question. Thus, our first conversations are with our mothers. Greenwood offers an explanation of how infants begin with affect expressions and species-typical behaviors to express themselves, move to communicating with gestures and inflected vocalization, and finally develop language. And, referential clarity increases with the development of the emotions and language. The child’s species-typical behavior patterns coupled with the mother’s intuitive parenting skills provides the necessary and sufficient conditions for generating a semantic lexicon. These natural and conventional signs have their declarative and imperative content secured by a kind of teleosemantics inspired by the work of Ruth Millikan.

These are bold hypotheses that Greenwood has offered. She additionally argues that the hypothesis above gives strong support to Transcranialism, or the Extended Mind hypothesis, about the emotions. It says that mental states and processes extend outside the nervous system. Intracranialists deny this claiming that the scaffolding provided by the world outside the body is simply that of “support”. That is, they claim Transcranialists conflate causation and constitution. Greenwood utilizes the work of Robert A. Wilson (2004) on the metaphysics of realization to challenge this. Roughly, a property R realizes G if it is plays the G-role or has the G-function. Philosophers of mind have typically assumed that the physical properties sufficient for mental roles or functions were exhausted by the intrinsic physical properties of individuals. However, this is exactly the assumption that Wilson and Greenwood challenge. According to Wilson, there are core and non-core realizers. Core realizers are those parts of a system which play a “crucial role” in producing or sustaining a property of interest. Non-core realizers are necessary but are not crucial for the producing or sustaining the property of interest. For example, a core realizer for fear is the amygdala whereas the thalamus is a non-core realizer. Transcranialism about emotions claims that the realization of emotions is radically wide; a total realization of an emotion can have core and non-core realizers located outside the individual experiencing the emotion.

As we have seen, Greenwood claims emotions are essentially ostensive-expressive devices that evolved by natural selection for interpersonal tasks and only later for intrapersonal ones. She also argues that Wilson’s model of radically wide realization provides the metaphysical machinery for defending transcranialism about human emotions. Going beyond earlier externalisms, she contents the internal and external resources are deeply functionally integrated and play complimentary roles in our emotions. The mind extends our emotions into the world, and the world extends into our emotions. It is “synchronous modulation” of the child and mother during the development of emotions and language which widely realizes those emotions.

Greenwood’s claims and arguments are extremely bold. Let me conclude by raising some points of criticism. Greenwood has effectively argued that human infant’s emotions develop through a dynamic coupling with their mothers. They are functionally integrated. I find the evidence she presents fairly convincing. If child and mother are functionally integrated with respect to the child’s emotions, then they are widely realized. If they are widely realized, then those emotions are transcranial. Therefore, those emotions are transcranial. First, like Victor of Aveyron, some feral children develop without the benefit of a mother or even a direct caregiver. They are raised by wolves as it were. Though they may be developmentally challenged in various ways, one might argue that they experience a full range of human emotions. This suggests that the dynamic coupling with a caregiver, and specifically a mother, is not necessary for the development of human emotions. Without good empirical evidence, I am suspicious of this claim. Anecdotal reports of feral children strike me as inconclusive at best. Second, let’s suppose that this dynamic coupling is required. Still, one might object even accepting that it is through this functional integration the emotions are widely realized, we needn’t accept that they are transcranial. Striking a match causes a fire at the end of the stick but only so if there is oxygen present. We treat the striking as the cause and the oxygen as a background condition. Thus, even if we grant that a core realizer of a child’s fear is the amygdala and non-core realizer are the mother’s assistance-producing devices, it seems that we can still appeal to the cause/background condition distinction. Through this, we can resist the more radical transcranialist’s claims. Of course, much more work is needed to make good on this claim. For example, the cause/background condition claim must be more than pragmatic. However, if we can, then I think we can argue that functional integration is causal and not constitutive. Third, let’s suppose that Greenwood has made her case that the emotion experienced by human children are transcranial. She grants human emotions move from interpersonal functions to intrapersonal ones. I doubt that emotions are generally interpersonal or intrapersonal en masse. Still, it is open whether at least some human emotions after childhood are exaptations to new intrapersonal challenges. If this is correct, then even if human emotions during childhood evolved to be transcranial they become intracranial later in life. The emotions of adults are screened-off from those of human children in a way that doesn’t threaten the project of psychologists and philosophers I mentioned at the beginning.

Regardless of my worries, Greenwood’s is an impressive book from which I learned quite a bit. I strongly encourage those interested in emotions and expression to read it. Your mother would have wanted you to.

In On Immunity: An Inoculation, essayist and author Eula Biss has given academics and clinicians interested in the public’s skepticism of vaccines, and of science skepticism more generally, a fresh look at what drives these phenomena. Despite public health’s continued success in maintaining high rates of coverage for vaccines across the United States, recent measles, mumps, and rubella outbreaks in the U.S. (and globally for that matter) have harmed lives and indicate cracks in the vaccine uptake façade. From a public health perspective, it’s all hands on deck to make sure vaccine coverage stays high. Biss’s outsiders’ view of these issues offers bioethicists, public health practitioners, and physicians much to consider as we address ongoing challenges to vaccination.

Do not read On Immunity expecting a scholarly analysis of the state of vaccine refusal and resistance. The book is instead part self-reflection (how Biss samples but rejects anti-vaccine sentiments), part observation (the ways vaccines both capture and reflect popular understanding and anxiety about the body, about germs, and about medicine more generally) and part research (into the history of anti-vaccine thought as well as its contemporary impact).

Throughout the book, Biss’s physician father acts as sort of a scientific straight man, laying out both the joys and challenges of medical and scientific practice. In one of these moments, Biss recalls how her father taught her about blood types, and about how both he and she were universal donors. With type O negative blood, Biss would come to understand her universal donor status “more as an ethic than as a medical concept” (18). This belief in a communitarian ethic runs throughout the book. “If we imagine the action of a vaccine not just in terms of how it affects a single body,” Biss writes, “but also in terms of how it affects the collective body of a community, it is fair to think of vaccination as a kind of banking of immunity.” “Contributions to this bank are donations to those who cannot or will not be protected by their own immunity,” she concludes (19).

For those of us who spend time considering vaccine policy, these are obvious points, as are the conclusions to be drawn from them. But what Biss offers its academic readers is a less jargon-filled and stilted way to talk about the importance and fear of vaccines, and thus provides some insight into what we might do to shore up vaccine coverage. One suggestion Biss has is to abandon the term “herd immunity.” In her analysis, it is a negative metaphor, one that “suggests we are cattle, waiting, perhaps, to be sent to slaughter.” “And it invites,” she continues, “an association with the term herd mentality, a stampede towards stupidity.” In its place, Biss suggests the concept of “shared immunity,” rooting the metaphor instead on natural examples like the cooperation of honeybees and collective problem solving. If the herd assumes we are foolish, the notion of shared immunity roots the nature of vaccine coverage in cooperation (21).

Some have read On Immunity as a weak embrace of anti-vaccinationism, if only to have the reader take a taste of it, understand its essence, and be “inoculated” against its impact (Oppenheimer 2014). But I read this book differently. In fact, this is less a vaccine-world Rashamon, and more of an opportunity for scholars and policymakers to view the challenges and mindset of anti-vaccine thought, through the eyes of a sympathetic yet disapproving observer.

Biss’s chapter on how popular misunderstandings of toxicity have seeped into anti-vaccine thought, for example, is especially relevant as policy makers and ethicists consider how to respond to the threats to herd or shared immunity. Fears of toxicity, which she acknowledges is a loosely defined idea in the public’s mind, can at once refer to the ingredients in vaccines, the accumulation of vaccines in the body, or environmental exposures more generally. Biss argues that such references to toxicity by both anti-vaccine boosters and the Gwyneth Paltrow-set “strikes me as an old anxiety with a new name” (75). While she acknowledges the impact and dangers of environmental pollutants, Biss believes that what the pre-germ theory idea of filth once represented “with its moralist air, the evils of the flesh,” today is now expressed in terms of toxicity. “The word toxic,” she writes, is a catch all term that “now condemns the evils of our industrialized world.” Theories of filth and toxicity “allow their subscribers to maintain a sense of control of their own health by pursuing personal purity” (75). This gets played out in a variety of ways, including our search for the “natural,” as well as in vaccine resistance.

An academic reader of the book may also consider Biss’s failure to correct the misinformation that the anti-vaccine community thrives on as a shortcoming, or even fatal flaw of the book (142). I do not share this concern. This book is not meant for the vaccine doubters or resistors who tout their wares on the internet and at alternative medicine conferences. It is instead meant for us: the ethicists, clinicians, and policy makers who are struggling with the challenges we face in an increasingly vaccine resistant or hesitant public. It may well be that the response to anti-vaccinationism is a question of policy and public health ethics: how much should we limit people’s civil liberties to protect the public health. But when I hear studies and pundits suggest that anti-vaccine skeptics are immovable and that we must institute our most draconian policies to preserve our collective health, I find myself the skeptic and worry that we as a field have given up too easily. At the very least, On Immunity offers a retort to this line of thinking, providing vaccine ethicists and policy makers with both rhetorical and practical ways (see above examples about a communitarian ethic, herd immunity, and toxicity) to view and push back against the anti-vaccine movement.

There is one line in the book that continues to resonate with me. Biss writes that “the belief that public health measures are not intended for people like us is widely held by many people like me” (24). While her thinking here is not surprising, it is perhaps the most fundamental challenge to the current anti-vaccine trend. And it is thinking like this that has given largely white, highly educated, and middle and upper middle class families the rationale to resist or refuse vaccination. It is a position of privilege that threatens the public health, a sense of privilege that is not simply the fault of the non-medical public. It is rooted in class and racial tensions that Biss highlights. In a visit to her son’s pediatrician, Biss questions the necessity of the hepatitis B vaccine. Her doctor tells her that it is a vaccine for the inner city, “designed to protect babies of drug addicts and prostitutes.” “In retrospect,” she recalls, “I am ashamed of how little of his racial code I registered.” “Relieved to be told that this vaccine was not for people like me,” she concludes, “I failed to consider what exactly that meant” (24).

But that failure is not hers alone. It is our failure—in ethics, in public health, and in medicine. If people continue to assume, as Biss puts it, that public health “is for people with less—less education, less health habits, less access to quality health care, less time and money” (24), then we will continue to struggle with this novel strain of anti-vaccinationism and be threatened by public health challenges that lie ahead.

Michael YudellDornsife School of Public HealthDrexel University
Philadelphia, PA, USA

REFERENCES

Oppenheimer, Mark. 2014. “This Book Empathizes with Anti-Vaxxers, Who Don’t Deserve Empathy.” The New Republic. September 29. Full article »

In this original and insightful new work, Alice Crary proposes that we see human beings and animals as creatures that are “inside ethics,” which is to say that they possess “characteristics that are simultaneously empirically discoverable and morally loaded” (4). This view rejects what Crary sees as the dominant paradigm in moral philosophy, wherein empirical observations about human beings and animals are viewed as morally neutral and shorn of any evaluative characteristics. Her view has implications for a range of topics in moral philosophy and bioethics, including debates about disability, moral status, moral individualism, animal ethics, and animal mindedness. Here, I’ll focus primarily on summarizing chapters 1-3—which contain what Crary refers to as the work’s central argument—before turning to a few thoughts and criticisms of that argument.

Chapter 1 lays out the broad paradigm in moral philosophy that Crary opposes—that of seeing human beings and animals as “outside ethics,” or devoid of empirically discoverable and objective moral characteristics. She traces the tendency to see human beings and animals as outside ethics to what she describes as a “hard metaphysic,” where objective moral values are not viewed as part of the fabric of the world, but things that we impose on a world that is itself morally neutral (14). Chapter 2 is devoted to arguing for the work’s central claim: that human beings and animals have empirically discoverable and objective moral characteristics.

In making this argument, Crary begins by establishing what moral characteristics are and discussing how we ascribe them to humans and animals. Moral characteristics are ethically inflected psychological categories—such as, for example, jealousy, guilt, fear, or happiness. Importantly, these categories “resist any meaningful reduction or translation to physical terms” (37). This is because, in applying these psychological categories to humans and animals, we necessarily invoke certain ethically loaded conceptions of what makes a good human or animal life that are not themselves reducible to physical terms (80). When, for example, researchers set out to study jealousy in dogs, “their efforts depend for their success” on an “understanding of canine life and of the place of jealousy within it” (79). Psychological characteristics are, in this sense, “only at home in human and animal lives in which some things matter in that they are, say, to-be-feared, to-be-sought, to-be-eaten, to-be-protected, or to-be-befriended” (88). In other words, we bring ethically loaded concepts of what makes a good human or animal life to bear on our understanding of the psychological characteristics of humans and animals.

But there is still the further claim that such moral characteristics are objective and empirically discoverable; in other words, that one can apply these characteristics in a genuinely descriptive manner. It might be the case, for example, that in attributing the concept of jealousy to dogs, we make a mistake—perhaps even a mistake that stems from a problematic tendency toward anthropomorphism on our part. If this thought is right, then our claims about dogs being jealous or afraid would not be truth-tracking or objective; they would be merely subjective expressions of our own emotions, preferences, or biases.

Crary resists this possibility by proposing that we reconceptualize our understanding of objectivity. She thinks that her opponents—in denying that moral characteristics are objective—rely on what she calls a narrow conception of objectivity. The narrow conception of objectivity takes the world to be “available to thought” in a manner that is “unmediated” by concepts (55). Further, proponents of the narrow conception think that this kind of connection with the world provides a firm foundation for empirical knowledge. Proponents of the narrow conception would deny that moral characteristics are objective because objectivity, for them, involves accessing the world in a manner unmediated by normatively- or morally-inflected concepts. To argue against the narrow conception of objectivity, Crary marshals arguments made by Wittgenstein, McDowell, and others, who resist the idea that there exists a non-conceptual “given” that can provide this kind of foundation for empirical knowledge (47-55). These arguments lead Crary to suggest a “wider” alternative to the narrow conception. Proponents of this wider conception of objectivity deny the existence of a non-conceptual “given” that can provide a foundation for empirical knowledge and affirm the conceptualist view that deploying normatively loaded concepts is necessary for acquiring empirical knowledge. If this wider conception of objectivity is right, then Crary has opened up a space in which we can start to see the ascription of moral characteristics to humans and animals as objective and truth-tracking—in other words, we can start to see humans and animals as “inside ethics.”

But in relying on a conceptualist view to defend the wide conception of objectivity in chapter 2, Crary recognizes a threat to her argument that non-human animals are “inside ethics” in virtue of their psychological qualities. This threat comes from the fact that conceptualist doctrines like the one that Crary defends in chapter 2 are often taken to imply that non-human animals “lack any but the most primitive qualities of mind” (93). In order to avoid this, and thereby show that our attribution of morally inflected psychological qualities to animals is not misguided, she urges us to recognize a continuum of concept-use that runs from being governed by immediate, biological drives, to primitive concept-use, to full rationality. She thinks that, just like we consider young children to be primitive concept-users, we should think about many non-human animals—she focuses primarily on dogs—in this way (113-18). So we should read certain dog behavior, for example, as trustworthy as opposed to “merely predictable” (120). Showing how conceptualism needn’t result in skepticism about animal minds allows Crary to claim that non-human animals have empirically observable, objective moral characteristics, so that when we label a dog’s trustworthy behavior as such, we are not engaging in mere misguided anthropomorphism.

The latter chapters of the book draw out what Crary sees as the moral upshot of understanding humans and animals as “inside ethics”: the recognition of moral characteristics in humans and animals calls for certain forms of moral response, like attention and concern (88). Furthermore, given that our empirical knowledge of humans and animals’ psychological qualities must draw on ideas about what matters morally in their lives, she argues in chapter 4 that this means that all human beings and animals are of moral concern, qua their status as human beings or animals (121). Chapter 7 applies her view to two issues in applied ethics: eating animals and experimenting on them. Here, she focuses on two nonfictional works: Jonathan Safran Foer’s Eating Animals and the documentary Project Nim (255). She argues that both works urge us to see animals as “inside ethics,” insofar as they portray various animals as “living lives of significance” that deserve certain sorts of moral attention, like sympathy or respect (265).

Throughout the work, Crary claims that her argument shows that all humans and all animals are inside ethics (121). However, I wonder whether—by Crary’s own lights—she is in fact able to retain this claim (121). Given her commitments, it seems to me that the scope of creatures who are inside ethics must be either narrower or broader than this: either it is the case that not all animals are inside ethics, or it is the case that all animals as well as all plants are inside ethics.

Let’s start with why the scope may have to be narrower. Consider Crary’s response to McDowell’s arguments about animal mindedness. McDowell draws a distinction between world and environment (1994, 105-07): humans occupy a normatively structured world, while non-rational animals merely occupy environments that are structured by mere biological imperatives. For McDowell, this means that all animals are not minded in the relevant sense and are controlled by mere biological drives. Crary’s denies this universal claim by showing how some animals are not best characterized as mere automata, following only biological drives (107).

However, in this discussion, Crary exclusively focuses on the ways in which domesticated animals, like dogs, are inside ethics (113-18). We can see how it makes sense to speak of dogs “who are integrated into household routines” as trustworthy as opposed to merely predictable, for example, because they are trained to abide by social norms in various ways (120). Trained dogs would be capable of having some degree of the “free, distanced orientation” from immediate biological impulses that McDowell attributes exclusively to rational human beings (1994, 117). But what of non-domesticated animals, wild animals, or animals that otherwise take no part in the human social world? By arguing that dogs are at least proto-concept-users, Crary may have successfully blocked the implication that all animals are mere automata; however, that does not entail the further claim that all animals, including non-domesticated ones, truly possess the kinds of psychological qualities Crary is interested in. Given this, I think Crary needs to give an argument for why non-domesticated animals possess such qualities. If such an argument is not forthcoming, then it seems like all Crary has shown is that domesticated animals are properly described as “inside ethics.”

There are (at least) two ways of avoiding this problem. One would be to argue that there is more than one route to being a concept-user. Perhaps, for example, domesticated dogs and wild bottlenose dolphins are both concept-users, but in different ways. This seems to me the most promising route out of this problem, but Crary does not develop this line of thought in Inside Ethics.

A second route is to drop the commitment that moral thought in her sense is truth-tracking or objective. Perhaps we ascribe concepts like fear or shame to non-domesticated animals anthropomorphically. Maybe there is even a case to be made that we should anthropomorphize non-domesticated animals this way, insofar as it increases sympathy for them or amplifies concern for their welfare. In other words, perhaps there are independent reasons we should think about creatures as being “inside ethics,” even if that sort of thinking is not objective or truth-tracking.

However, if Crary drops this commitment to objectivity, she runs into other problems. Namely, it then becomes unclear why we shouldn’t consider a much wider class of creatures to be “inside ethics.” Why not, for example, see individual plants as things about which we can have morally loaded empirical knowledge? After all, in order to understand features of any given plant—why its leaves droop at night, or why its stems turn certain colors when lacking nutrients—we must draw upon ideas about what makes life good for plants of that kind. Goethe, for example, takes up this attitude toward plants in his work The Metamorphosis of Plants:

The nub of tranquil life, kept safe and dry,
Swells upward, trusting to the gentle dew,
Soaring apace from out the enfolding night.
Artless the shape that first bursts into light—
The plant-child, like unto the human kind—
Sends forth its rising shoot that gathers limb
To limb, itself repeating, recreating… (2009, 2-3)

Here Goethe clearly anthropomorphizes plants, attributing to them certain kinds of psychological properties that they do not, in fact, have. But there is no question that this poem attempts to achieve a certain kind of sympathetic understanding of the goods of plant life, and what it might mean for that life to go well. Does this mean, then, that we must extend moral concern to individualplants, as Crary suggests we should to humans and animals? This would make the scope of beings that are inside ethics much broader than Crary claims. This implication would also be unwelcome: if beings that are “inside ethics” call for “certain forms of moral attention and concern” (88), and if plants, too, are inside ethics, then it seems we must devote moral attention and concern to individual plants. This requirement could make moral thought far too demanding.

Crary needs the objectivity component of the project in order to block this move. With this in place, she could argue that our interpretation of a plant as possessing psychological properties— “trusting to the gentle dew,” for example—is mere poetic anthropomorphism, because we know that plants do not possess concepts, and are thus not minded in the relevant sense. But this move risks coming at the cost of Crary’s commitment to the idea that all animals—not simply domesticated ones—are “inside ethics,” since the apparent moral features of non-domesticated animals may also be appropriately characterized as mere poetic anthropomorphism. What is in fact included inside ethics may therefore be either broader or narrower than Crary claims.

That said, this work has much to offer, and is a breath of fresh air in many respects. Crary is right that the argument of her second chapter fleshes out and defends previously undefended aspects of Philippa Foot’s project in Natural Goodness (2001). Inside Ethics can also be read as a way of elaborating upon and defending Cora Diamond’s brief, suggestive, and intriguing remarks in her famous essay “Eating Meat and Eating People,” wherein Diamond urges us to think of non-human animals as creatures deserving of pity (1978). Crary’s work also poses a distinctive and welcome challenge to the dominant trend in moral philosophy of seeing living beings as “outside ethics,” and calls for those who subscribe to that outlook to defend it. Though not without its flaws, Inside Ethics ultimately offers a fresh way of thinking about moral philosophy that is stimulating, ambitious, and original.